Friday, January 11, 2008

Must Be Happier

It's not easy to define happiness, but someone's got to do it. Over at the Furious Seasonsblog, Philip Dawdy does a magnificent job reviewing the debate over the nature of happiness taking place among psychiatrists in this month's issue of the American Journal of Psychiatry.

In the pathology-focused world of psychiatry, happiness is the absence of depression. But how absent should it be? Should we settle for "response," which is defined as at least a 50% improvement, or should we insist on "remission," generally defined as a score of 7 or less on the widely used Hamilton Depression Scale? Ever since Wyeth and Micheal Thase released their study showing (purportedly) that Effexor leads to a higher remission rate than SSRIs, the field has decided that remission is the way to go. And this is the outcome variable that was chosen for NIMH's STAR-D study, which showed that it's very, very hard to bring patients to remission, no matter how many meds you throw at them.

As eloquently argued by Dawdy and in some of the letters in the Journal, remission is an unrealistic goal for most patients, and stacking one medication on top of another may simply cause a succession of side effects. Leaving well enough alone is sometimes the best course of action, and dropping the obsession with finding the very best medication allows a focus on psychotherapy, a lost art form in this era of 15-minute psychiatrists.

5 comments:

therapyfirst
said...

As usual, Dr Carlat is bringing attention to the important points in our field--it's not just a biochemical imbalance and in need of a quick fix, but instead treatment is about the complete picture. In the end, what illness, psychological or physical, is cured? Remission is a subjective assessment in the end.

It still amazes me how many psychiatrists seem to forget that there is an intervention called psychotherapy.

Just found your blog through my reader recommendations..what a great find! Earlier this morning we were talking about patients who are responding to meds, but come in decompensated because of stress/season/external reasons. Is there any justification for adding/increasing anti-depressants for such patients? I think not.

Yes, "getting the meds right" can be a tedious process. It takes patience, compassion, and knowledge, not to mention awareness of other physical issues such as how long-neglected psychiatric illness has affected health routines and perhaps adversely affected thyroid, hormones, and the like.

No one said it was easy. But to give up on a patient and insist that they make up for a clinician's deficits with ill-fitting psychotherapy? Geez, where's the alleged investigative journalists to create a frenzy on that one?

I think I'm starting to see why some psychiatrists are so against medications. They think they should be easier to use, and when they're not, they blame pharma instead of their own lack of understanding. Boy, that's quite a revelation.

Nehaj wrote:Earlier this morning we were talking about patients who are responding to meds, but come in decompensated because of stress/season/external reasons. Is there any justification for adding/increasing anti-depressants for such patients? I think not.------It doesn't sound like you have any better ideas. Would you not think to ask the patient about exposure to sunlight, sleep, changes in diet,or other "external reasons"?

You would just think ply with more andidepressants or dismiss it as a case for psychotherapy?

Would it ever occur to you that maybe you've also prescribed the wrong medication, and the cumulative effects of that choice are coming to the fore?

The point I was making was that I wouldn't ply the patient with anti-depressants/dismiss it, as you so eloquently put it, with psychotherapy. I would try to see if the change is something we can work on.

For example, if its a part-of-life process like death, I would allow for the normal grief process/refer for supportive therapy if the bereavement is complicated.

If it is something that can be modified, like poor sleep hygiene, we would work on that.

Would it ever occurred to me that the patient is on wrong medication? Depends upon the evidence. If this is a patient who has been stable on that same medication for the past year, I would look elsewhere first.

Um, and could you tone down the personal attacks, please? They do not make for a useful discussion.